3.0 Conclusions 3.1 Findings as to Causes and Contributing Factors The Bradley take-off weight was likely used to generate the Halifax take-off performance data, which resulted in incorrect V speeds and thrust setting being transcribed to the take-off data card. The incorrect Vspeeds and thrust setting were too low to enable the aircraft to take off safely for the actual weight of the aircraft. It is likely that the flight crew member who used the Boeing Laptop Tool (BLT) to generate take-off performance data did not recognize that the data were incorrect for the planned take-off weight in Halifax. It is most likely that the crew did not adhere to the operator's procedures for an independent check of the take-off data card. The pilots of MKA1602 did not carry out the gross error check in accordance with the company's standard operating procedures (SOPs), and the incorrect take-off performance data were not detected. Crew fatigue likely increased the probability of error during calculation of the take off performance data, and degraded the flight crew's ability to detect this error. Crew fatigue, combined with the dark take-off environment, likely contributed to a loss of situational awareness during the take-off roll. Consequently, the crew did not recognize the inadequate take-off performance until the aircraft was beyond the point where the take-off could be safely conducted or safely abandoned. The aircraft's lower aft fuselage struck a berm supporting a localizer antenna, resulting in the tail separating from the aircraft, rendering the aircraft uncontrollable. The company did not have a formal training and testing program on the BLT, and it is likely that the user of the BLT in this occurrence was not fully conversant with the software. 3.2 Findings as to Risk Information concerning dangerous goods and the number of persons on board was not readily available, which could have jeopardized the safety of the rescue personnel and aircraft occupants. Failure of one of the airport emergency power generators to provide backup power prevented the operation of some automatic functions at the fire hall after the crash alarm was activated, increasing the potential for a delayed response. Grid map coordinates were not used to direct units responding to the crash and some responding units did not have copies of the grid map. The non-use of grid coordinates during an emergency could lead to confusion and increase response times. Communication difficulties encountered by the emergency response agencies complicated coordination and could have hampered a rescue attempt or quick evacuation of an injured person. A faulty aircraft cargo loading system prevented the proper positioning of a roll of steel, resulting in the weight limits of positions LR and MR being exceeded by 4678kg (50percent). The company increase of the maximum flight duty time for a heavy crew from 20to 24hours increased the potential for fatigue. Regulatory oversight of MKAirlines Limited by the Ghana Civil Aviation Authority (GCAA) was not adequate to detect serious non-conformances to flight and duty times, nor ongoing non-adherence to company directions and procedures. The delay in passing the new Civil Aviation Act, 2004 hindered the GCAA's ability to exercise effective oversight of MK Airlines Limited. Company planning and execution of very long flight crew duty periods substantially increased the potential for fatigue. The company expansion, flight crew turnover, and the MKAirlines Limited recruitment policy resulted in a shortage of flight crew; consequently, fewer crews were available to meet operational demands, increasing stress and the potential for fatigue. There were no regulations or company rules governing maximum duty periods for loadmasters and ground engineers, resulting in increased potential for fatigue induced errors. The MKAirlines Limited flight operations quality and flight safety program was in the early stages of development at the time of the accident; consequently, it had limited effectiveness. The berms located at either end of runways06 and 24 were not evaluated as to whether they were a hazard to aircraft in the runway overrun/undershoot areas. The operating empty weight of the aircraft did not include 1120kg of personnel and equipment; consequently, it was possible that the maximum allowable aircraft weights could be exceeded unknowingly. The ground handling agent at Halifax International Airport did not have the facilities to weigh built-up pallets that were provided by others. Incorrect load weights could result in adverse aircraft performance. Some MK Airlines Limited flight crew members did not adhere to all company SOPs; company and regulatory oversight did not address this deficiency. 3.3 Other Findings An incorrect slope for Runway 24 was published in error and not detected; the effect of this discrepancy was not a significant factor in the operation of MKA1602 at Halifax. The occurrence aircraft was within the weight and centre of gravity limits for the occurrence flight, although the allowable cargo weights on positions LR and MR were exceeded. Based on engineering simulation, the accident aircraft performance was consistent with that expected for the configuration, weight and conditions for the attempted take-off at Halifax International Airport. There have been several examples of incidents and accidents worldwide where non adherence to procedures has led to incorrect take-off data being used, and the associated flight crews have not recognized the inadequate take-off performance. No technical fault was found with the aircraft or engines that would have contributed to the accident. 4.0 Safety Action 4.1 Action Taken 4.1.1 Safety Advisory A040058-1 On 20 October 2004, the Transportation Safety Board of Canada (TSB) issued Safety Advisory A040058-1 (Verification of Cargo Weights) to Transport Canada (TC). The Safety Advisory indicated that TC might wish to examine the adequacy of cargo handling procedures, both inside and outside Canada, and, in particular, the adequacy of load weight verification and the regulatory oversight of these issues. On 09 December 2004, TC responded to Safety Advisory A040058-1. The letter quoted several regulations applicable to commercial operations: International Civil Aviation Organization (ICAO) standards and recommended practices, Canadian Aviation Regulations, Joint Aviation Requirements (JARs), and Federal Aviation Regulations (FARs). TC stated that the intent of the regulations is to ensure that the actual weight of the cargo, including the weight of the contents, the packing material, the packaging, the pallet or unit load device, the strapping, the wrapping, and any other device or material being transported with the cargo is accounted for in the total weight of the cargo. TC further stated that the regulations clearly indicate that it is an operator's responsibility to ensure that proper weighing procedures are in place to support its operations. It is TC's position that the existing regulations and standards adequately address the issues raised in the Safety Advisory. However, in light of the recent accident in Halifax, Nova Scotia, and to reinforce the absolute necessity for accurate load control, TC published a Commercial and Business Aviation Advisory Circular on this issue on 04June2005. 4.1.2 Safety Advisory A040059-1 On 22 October 2004, the TSB issued Safety Advisory A040059-1 (Runway Slope Information - Publication Errors) to TC. The Safety Advisory raised a concern about the accuracy of published runway slope information. The slope datum for Runway24 at Halifax International Airport published in Canadian aeronautical information publications was incorrectly depicted as 0.17percent down, when it should have read 0.17percent up. The Safety Advisory suggested that TC might wish to ensure that similar runway slope information errors do not exist for other aerodromes. A review of quality assurance measures regarding the provision and depiction of aerodrome information in Canadian flight information publications was suggested. On 09 December 2004, TC responded to Safety Advisory A040059-1. TC indicated that a preliminary review has not uncovered further errors in published runway slope data. The error in the Halifax data is the result of a human transposition error. The error in the slope value for Runway24 was discovered in the course of this accident investigation. TC was advised of the error, and a NOTAM (Notice to Airmen) was issued instructing holders of the Canada Air Pilot to delete the slope information for all runways at the Halifax International Airport. Subsequently, it was discovered that, in accordance with NAV CANADA's Aeronautical Information Publication (A.I.P. Canada) specifications, only slope values greater than 0.3percent are published. Therefore, a second NOTAM was issued, instructing holders of the applicable documents to re-insert the slope value for Runway33, and delete the value for Runway24. Additionally, as a result of this Safety Advisory, an Aerodrome Safety Urgent Bulletin was sent to TC regional offices for distribution to all airports and registered aerodromes. The Urgent Bulletin reminds all airport/aerodrome operators of their responsibility to verify the accuracy of all published data, and to report immediately, via a NOTAM, the corrections to be made to aeronautical information publications. Direction concerning the methodology for the calculation of runway slope data is being reviewed and coordinated with NAV CANADA and other interested stakeholders. NAV CANADA subsequently advised the TSB that, between 01January2004 and 01October2004, only two requests were received to amend runway slope information contained in its aeronautical information publications. After the issue of Safety Advisory A040059-1 and up to 01December2005, NAV CANADA had received a total of 73 requests to amend or to add runway slope information. 4.1.3 Ghana Civil Aviation Authority In a letter dated 01November2004, the Ghana Civil Aviation Authority (GCAA) instructed MK Airlines Limited to cease use of the Boeing Laptop Tool (BLT) until such time as approval is given by the GCAA. Additionally, the GCAA instructed MK Airlines Limited to comply with the crew rest requirements listed in Section8.11 of the Ghana Civil Aviation Regulations (GCARs) until the company submits a new schedule for approval; and apply Section8.11.1.3(a)(4) of the CGARs for loadmaster rest and Section9.4.1.16 of the CGARs for ground engineer crew rest. 4.1.4 MK Airlines Limited 4.1.4.1 Notices to Flight Crew On 20 October 2004, MK Airlines Limited issued a Notice to Flight Crew that stated, Loadmasters and Station Officers are required to query weights on dead-load weight statements when two and/or several pallets are reflected at or near the same weights. Where necessary, a check weight on a suitable calibrated scale must be carried out prior to loading. DO NOT under any circumstances accept freight that has not been weighed over a calibrated and current aircraft pallet scale from a Company approved handling agent/company. Any occurrence of any nature in this regard requires an occurrence report to be completed and submitted to the FSO [Flight Safety Officer]. On 20 October2004, MK Airlines Limited issued a Notice to Flight Crew on the above topic that stated, With immediate effect to avoid any confusion, the weight and index for the total number of people on board (flight deck and all passengers) must be shown in the 'correction' box in both the B747 and DC-8 load sheets. The basic weight does not include 'crew'. Within two weeks of the accident, MKAirlines Limited issued a Notice to Flight Crew to immediately cease use of the BLT and use alternate procedures. A formal submission has been made to the United Kingdom Civil Aviation Authority (CAA) in accordance with Temporary Guidance Leaflet No.36: Approval of Electronic Flight Bags (EFBs). On 03 February 2005, MK Airlines Limited issued a Notice to Flight Crew on the above topic that stated that the EFBs (JeppView computers) are not to be used until such time as their use has been formally approved in compliance with the JAR guidelines. 4.1.4.2 Operations At the request of MK Airlines Limited, the United Kingdom government, in cooperation with the GCAA, conducted a full audit for ICAO compliance on 16November2004. As a result of the audit, MKAirlines Limited decided to obtain JAR compliance in accordance with the United Kingdom authorities. The United Kingdom CAA publication entitled Avoidance of Fatigue in Air Crews (CAP371) lists the regulations for the avoidance of fatigue in aircrew. MK Airlines Limited has asked the GCAA for approval to use this flight time limitation scheme and has amended its operations manual (OM) accordingly. This scheme was approved in May2005 and has been fully implemented, and United Kingdom CAA inspectors are monitoring compliance. A crew notice was issued concerning the noting of duty times on voyage reports to enable better monitoring of required rest times. The MK Airlines Limited rostering staff has been briefed on the CAP371 limitations and will monitor crew scheduling with in-house developed software to prevent exceedences. Crews were briefed on the new flight time limitations and their responsibilities for compliance. Flight documents are subject to close inspection to ensure that captain's discretion reports are completed when required. A crew notice was issued concerning counselling to reduce fatigue and stress in light of the accident and the continued political and security situation in southern Africa. A new pay scheme introduced in December2004 improved the financial security of crew members and has been well received. The audit program of ground service contractors has been enhanced by the qualification of MK Airlines Limited loadmasters to the British Standards Institution (BSI) Lead Assessor standard. More detailed audit procedures have been developed under control of the newly appointed Director, Safety and Quality. The new Safety and Quality Department will coordinate audit activities across the technical, operational, security, and traffic disciplines. A safety management system was established throughout the company, and a new company safety policy was drafted. A program of flight data monitoring is being implemented as part of the flight operations quality system. This forms part of the safety management system, which integrates safety, quality, and security management of the company. Key staff attended a flight operations quality assurance course from 04 April to 07 April 2005, at Cranfield University, United Kingdom. A safety culture questionnaire was drafted and included in the latest company safety magazine to acquire employee feedback. 4.1.4.3 Training There have been extensive revisions to the training manual under United Kingdom CAA guidance to achieve JAR compliance. A new Assistant Training Manager was appointed, who has an extensive background in training management. Training is now compliant with JAR-FCL (flight crew licensing)/JAR-OPS (operations) requirements. Non-JAR-licensed aircrew have commenced study courses for JAR licences. Numerous companies and consultants were contracted or employed to oversee training standards: CTC Crew Training Centre, Bournemouth, United Kingdom - Type Rating Instructor (TRI) training. Global Air Training, Cheshire, United Kingdom - Crew Resource Management Instructor (CRMI) and Security Instructor training. Consultant - former Flight Operations Training Inspector, United Kingdom CAA. Responsibilities include monitoring instructor training standards. Consultant - former British Airways B747 Type Rating Examiner (TRE). Providing expertise in B747 type specific instructor training and standardization. Assistant Training Manager - former British Airways Senior Flight Engineer Instructor. Specific responsibilities include ensuring that training documentation and policies under development are of the required standard before submission to authorities. The company's OM (PartA, Section8 - Draft for approval by United Kingdom CAA) has been updated with various flight briefings to improve the level of situational awareness. Procedures were developed to ensure continued alignment of company training manuals with current national and international regulations and manufacturer's service bulletins. The training record system for each fleet was reviewed and aligned with the requirements of the training manual. A training expiry database was developed and will be reviewed to ensure that PartD, JAR-FCL requirements are met. Airworthiness directives and manufacturers service bulletins procedures are in Section2.11 of the maintenance control manual and are being rewritten in the Maintenance Organization Exposition to comply with Section145 of the JARs. An Information Management Department was established. A system has been developed to improve the crew qualification system for categoriesB and Caerodromes. Crew participation in information gathering and updating of aerodrome information has been implemented, incorporating a risk assessment and controlled flight into terrain analysis. PartC of the OM now includes route and aerodrome briefs. In addition to the air operating certificate (AOC) application, MKAirlines Limited will apply for Type Rating Training Organization (TRTO) in accordance with the JARs. MKAirlines Limited is in the process of publishing a TRTO manual for approval, which will contain all the requirements for instructors, instructor training, standards, and facilities. MK Airlines Limited has initiated a process to ensure that all company instructors and examiners are qualified to JAR-FCL, SubpartI. For example: Section 680 of JAR-FCL, Issue4, has been distributed to all potential TRI and TRE for licensing purposes. Authorization and accreditation for TRIs and TREs will be sought only after licences have been issued and all criteria in sections1.365 and 1.405of JAR FCL, and CAA standards document24, version4, have been met. In respect of the above, 14instructors have attended the JAR-approved TRI course at the CTC Crew Training Centre in Bournemouth. This training included CRMI (simulator/line) training. Three B747 training personnel have completed a TRI course on the B747 and have received approvals from the United Kingdom CAA. A standardization course is planned for the above instructors as soon as they have gained the necessary experience for approval asTRE. United Kingdom CAA-recommended persons will conduct standardization courses when instructors are upgraded from TRI to TREstatus. Four instructors (two pilots, one flight engineer and one loadmaster) have completed a JAR-approved CRMI (Ground) course at Global Air Training in Cheshire. The first Boeing 747 training course, in accordance with the new JARs, commenced in May2005. Work is under way at the company operations centre at Landhurst to add a Training Department wing to the existing structure. The new wing will house the Boeing747 simulator, the Training Department personnel offices, and the Safety and Quality Department. Proficiency check rides for each flight crew member have been updated to reflect the requirements of sections1.240, 1.295 and 4.240 of JAR-CFL, Appendix2. MKAirlines Limited has initiated a biennial technical ground training program for aircraft systems. Syllabus and course material comply with SubpartN of JAR-OPS. MKAirlines Limited has completed a program of initial and recurrent training for loadmasters to include crew resource management training. The chief loadmaster attended CRMI training from 10 January to 14January2005. Eight 3-day courses were conducted for all loadmasters between 16January and 12February2005. Enhanced ground proximity warning systems (EGPWS) have been added to the ground and simulator training for the B747fleet. A two-hour EGPWS lecture was programmed for Januaryto June2005 during recurrent training. An interactive CD ROM was issued to each crew member for home study. A biennial training requirement for aircraft performance and de-icing was added to the recurrent ground training program. De-icing holdover times in the OM, PartA, Section8.2.4.8.3, were amended on 21December2004 to bring them in accordance with the Association of European Airlines tables (19thedition, September2004). A Crew Notice was issued on 21December2004 to ensure crew awareness and to provide interpretation information. 4.1.4.4 European Aviation Safety Agency Certification MK Airlines Limited has applied for a United Kingdom AOC. The company organization has been revised to comply with or surpass the JARs, with the addition of several new, full-time appointments of highly qualified staff. The AOC project plan is managed by the Director, Safety and Quality and was completed in late2005. In support of the AOC application, the following activity has been initiated and/or completed: The position of Director, Safety and Quality was created. The new Director, Safety and Quality is an airline transport pilot licence holder with extensive aircrew, safety management system and specialized regulatory experience. The Flight Safety Officer (Accident Prevention Advisor) is now part of the coordinated safety team. An Aircrew Liaison Officer has been appointed as Flight Operations Quality Assurance interface with a confidential safety management function. The position of Ground Operations Manager was created and filled. The position of Training Manager was created and filled. The position of Assistant Training Manager was created and filled. The position of Director, Safety and Quality was created. The new Director, Safety and Quality is an airline transport pilot licence holder with extensive aircrew, safety management system and specialized regulatory experience. The Flight Safety Officer (Accident Prevention Advisor) is now part of the coordinated safety team. An Aircrew Liaison Officer has been appointed as Flight Operations Quality Assurance interface with a confidential safety management function. The position of Ground Operations Manager was created and filled. The position of Training Manager was created and filled. The position of Assistant Training Manager was created and filled. Terms of reference in the company OM for these positions were revised for United Kingdom CAA approval. PartD, Training, of the OM was re-written to meet the JAR-FCL requirements and was submitted to the United Kingdom CAA for approval. This document has recently been approved. A revised B747 JAR-compliant minimum equipment list, based on the United Kingdom CAA master minimum equipment list, was submitted for approval. Changes were required and the amended version has been resubmitted as part of the AOC application. The newly appointed Ground Operations Manager has implemented tighter oversight of contracted ground handling companies. 4.1.4.5 Airworthiness A full check of aircraft equipment by the United Kingdom CAA was undertaken and confirmed that all aircraft were fully ICAO-compliant. Fuelling and loading procedures were reviewed to ensure standardization across both B747 and DC-8 fleets. In February 2005, the company commenced the application process for European Aviation Safety Agency (EASA) PartM (maintenance management) and EASA Part 145approval. In March2005, MKAirlines Limited started the recruitment of EASA Part 66 licensed staff and introduced training for existing staff to convert licences. In the first six months of2005, the company undertook or completed several safety actions regarding airworthiness: Transportation Safety Board of Canada - AVIATION REPORTS - 2004 - A04H0004 Transportation Safety Board of Canada Common menu bar links Fran�ais Home Contact Us Help Search canada.gc.ca REPORTS AVIATION 2004 A04H0004 Institutional links Main Links TSB Home Proactive Disclosure Marine Pipeline Rail Air Air Investigation Reports Recommendations and Assessments of Responses Board Concerns Air Statistics Reporting an Air Occurrence Air Investigation Reports Recommendations and Assessments of Responses Board Concerns Air Statistics Reporting an Air Occurrence AVIATION REPORTS - 2004 - A04H0004 The Transportation Safety Board of Canada (TSB) investigated this occurrence for the purpose of advancing transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability. Synopsis On 14 October 2004, an MK Airlines Limited Boeing 747-244SF (registration 9G-MKJ, serial number22170) was being operated as a non-scheduled international cargo flight from Halifax, Nova Scotia, to Zaragoza, Spain. At about 0654 coordinated universal time, 0354 Atlantic daylight time, MK Airlines Limited Flight1602 attempted to take off from Runway24 at the Halifax International Airport. The aircraft overshot the end of the runway for a distance of 825feet, became airborne for 325feet, then struck an earthen berm. The aircraft's tail section broke away from the fuselage, and the aircraft remained in the air for another 1200feet before it struck terrain and burst into flames. The aircraft was destroyed by impact forces and a severe post-crash fire. All seven crew members suffered fatal injuries. Ce rapport est galement disponible en franais. Minister of Public Works and Government Services 2006 Cat. No. TU3-5/04-2E ISBN 0-662-43546-X How This Report Is Organized MK Airlines Investigation Report Appendices Transportation Safety Board of Canada - AVIATION REPORTS - 2004 - A04H0004 Transportation Safety Board of Canada Common menu bar links Fran�ais Home Contact Us Help Search canada.gc.ca REPORTS AVIATION 2004 A04H0004 Institutional links Main Links TSB Home Proactive Disclosure Marine Pipeline Rail Air Air Investigation Reports Recommendations and Assessments of Responses Board Concerns Air Statistics Reporting an Air Occurrence Air Investigation Reports Recommendations and Assessments of Responses Board Concerns Air Statistics Reporting an Air Occurrence AVIATION REPORTS - 2004 - A04H0004 Appendices Appendix A - Flight Data Recorder Engine Data Comparison Between Bradley and Halifax Appendix B - Flight Data Recorder Flight Controls Comparison Between Bradley and Halifax Appendix C - Take-off Sequence Appendix D - Sequence of Events Appendix E - Glossary AppendixA-Flight Data Recorder Engine Data Comparison Between Bradley and Halifax AppendixB-Flight Data Recorder Flight Controls Comparison Between Bradley and Halifax Appendix C - Take-off Sequence Appendix D - Sequence of Events Appendix E - Glossary 1.0 Factual Information 1.1 History of the Flight The series of flights for this crew originated at Luxembourg-Findel Airport, Luxembourg, on 13October2004, as MK Airlines Limited Flight1601 (MKA1601),1 destined to Bradley International Airport, Windsor Locks, Connecticut, United States. The aircraft operated as MK Airlines Limited Flight1602 (MKA1602) from Bradley International Airport to Halifax International Airport, Nova Scotia, and was to continue as MKA1602 to Zaragoza, Spain, and return to Luxembourg. The flights were operating with a heavy crew,2 comprised of two captains, one first officer, and two flight engineers. A loadmaster and a ground engineer were also on board. The crew members for MKA1601/MKA1602 arrived at Luxembourg-Findel Airport at different times and dates. The captain and first officer of MKA1601, and flight engineer of MKA1602 operated a flight from Nairobi, Kenya, to Luxembourg-Findel Airport on October 12. The captain of MKA1602 and flight engineer of MKA1601 arrived in Luxembourg from Johannesburg, South Africa, on October12 as operating crew of their first flight after a two-week period off duty. On October13, the ground engineer and loadmaster arrived at Luxembourg as crew on the occurrence aircraft. The planned departure time for MKA1601 was 1000 coordinated universal time (UTC).3 At 0848, just before the crew's departure from the hotel in Luxembourg, the MKA1601 captain received a phone call from the MK Airlines Limited station liaison officer in Luxembourg, advising of a delay to the planned departure time due to the late arrival of the aircraft and late preparation of the cargo. The captain, first officer, and flight engineer of MKA1601 checked out of the hotel at 0925. At 0941, the captain was advised that the aircraft loading was under way, and the captain, first officer, and flight engineer proceeded to the airport. The captain and flight engineer of MKA1602 checked out of the hotel at 1052 and proceeded to the airport. When the MKA1601 captain arrived at the airport, he received the flight documentation from the Luxembourg station liaison officer. The flight documentation was prepared by the MK Airlines Limited operations centre in Landhurst, East Sussex, United Kingdom. It included the flight brief, the trip schedule, flight routing, weather, flight plan, planned fuel requirements, and planned payload. After the captain reviewed the flight documentation, he requested that 4000kilograms (kg) of cargo be offloaded to carry additional fuel. The crew made the necessary adjustments to their flight documentation. Another delay developed when the loadmaster noted that some of the pallets were contaminated with soil and would not be accepted by the authorities at Bradley International Airport. A vacuum cleaner was obtained and the MK Airlines Limited station liaison officer and loadmaster began to clean the pallets. So as not to delay the flight unnecessarily, the loadmaster took the vacuum cleaner on board to finish cleaning the pallets en route. The flight departed at1556. The first officer was identified as the pilot communicating with air traffic control (ATC) for the flight from Luxembourg to Bradley, except for a three-hour period during which time the voice communicating with ATC was that of another crew member. MKA1601 landed at Bradley International Airport at2322. At Bradley International Airport, all the cargo from Luxembourg-Findel Airport was offloaded. However, the cargo loading at Bradley was prolonged due to unserviceabilities with the aircraft's cargo loading system. With a captain and flight engineer crew change, MKA1602 departed Bradley International Airport for Halifax International Airport at 0403 on October14, carrying another delay. The MKA1602 captain was the pilot communicating with ATC; the first officer was the pilot flying(PF). MKA1602 landed on Runway24 at Halifax International Airport at 0512 and taxied to the ramp. After shutdown, loading of the aircraft was started. During the loading, two MK Airlines Limited crew members were observed sleeping in the upper deck passenger seats. After the fuelling was complete, the ground engineer checked the aircraft fuelling panel and signed the fuel ticket. The aircraft had been uploaded with 72062kg of fuel, for a total fuel load of 89400kg. The ground engineer then went to the main cargo deck to assist with the loading. Once the loading was complete, the ramp supervisor for the ground handling agent went to the upper deck to retrieve the MKA1602 cargo and flight documentation. While the loadmaster was completing the documentation, the ramp supervisor visited the cockpit and noted that the first officer was not in his seat. Approximately 10minutes later, the ramp supervisor, with the documentation, left the aircraft. At 0647, the crew began taxiing the aircraft to position on Runway24, and at 0653, the aircraft began its take-off roll. See Section1.11.4 of this report for a detailed sequence of events for the take-off. During rotation, the aircraft's lower aft fuselage briefly contacted the runway. A few seconds later, the aircraft's lower aft fuselage contacted the runway again but with more force. The aircraft remained in contact with the runway and the ground to a point 825feet beyond the end of the runway, where it became airborne and flew a distance of 325feet. The lower aft fuselage then struck an earthen berm supporting an instrument landing system (ILS) localizer antenna. The aircraft's tail separated on impact, and the rest of the aircraft continued in the air for another 1200feet before it struck terrain and burst into flames. The final impact was at latitude 4452'51N and longitude 06330'31W, approximately 2500feet past the departure end of Runway24, at an elevation of 403feet above sea level (asl). The aircraft was destroyed by impact forces and post-crash fire. All persons on board (seven crew members) were fatally injured. 1.2 Injuries to Persons 1.3 Damage to the Aircraft The first damage to the aircraft occurred when, on rotation, the aircraft's lower aft fuselage struck the runway twice and remained on the ground to a point 825 feet beyond the end of Runway 24. Severe damage occurred when the aircraft's lower aft fuselage struck the berm and the vertical stabilizer and both horizontal stabilizers separated from the fuselage. The final impact was in a wooded area where impact forces and an extensive post-crash fire destroyed the remaining aircraft structure forward of the aft pressure bulkhead (seePhoto1). Photo1.Main fuselage and number 4 engine 1.4 Other Damage Grass was uprooted in the area beyond the end of the runway where the aft section of the aircraft fuselage had dragged on the ground; as well, a number of approach lights for Runway06 were destroyed. The ILS localizer antenna structure sustained significant damage when the aircraft struck the berm. Telephone and power lines adjacent to the main crash site were severed just before final impact. The surrounding wooded area was heavily damaged by the post-crash fire. Unburned fuel contaminated the soil in the immediate area of the crash site, requiring an extensive environmental clean-up. 1.5 Personnel Information 1.5.1 General The operating flight crew of MKA1602 consisted of one captain, one first officer, and one flight engineer. The captain and flight engineer of MKA1601, a ground engineer, and a loadmaster were also on board. 1.5.2 Operating Captain The pilot-in-command (operating captain) of MKA1602 held a Ghanaian airline transport pilot licence (ATPL) with a valid instrument rating. He was qualified and certified in accordance with the Ghana Civil Aviation Regulations (GCARs). His licence was annotated with the remark holder to wear spectacles which correct for near vision and shall have available a second pair whilst exercising the privileges of the license. Based on a review of the captain's medical records, there was no indication of any pre-existing medical condition or physiological factors that would have adversely affected his performance during the flight. The captain had been with the company since its inception and started flying the McDonnell Douglas DC-8 with MKAirlines Limited in1990. He was in one of the first groups of company pilots to transition to the Boeing 747-200 (B747). The captain successfully completed his United States Federal Aviation Administration (FAA) type rating training on the B747 in1999 at the Pan Am Training Center in Miami, Florida. The captain's total flying time on the B747was approximately 4000hours. In 2000, the company changed its B747 standard operating procedures (SOPs) and required all B747 flight engineers and pilots to undergo additional training. During this additional training, the captain had some difficulties adjusting to the new SOPs and his training was suspended. After two weeks of review and study, the captain returned to training and completed the course without further difficulty. Records indicate that there were instances where supervisory pilots had to counsel the captain regarding non-adherence to SOPs; however, in the period before the accident, he had demonstrated a marked improvement. The captain trusted other crew members to perform their duties with minimal supervision. He was not comfortable using personal computers and software, such as the Boeing Laptop Tool (BLT) (see Section1.18.1 of this report). He was more comfortable using manual methods to complete performance calculations, such as using runway analysis charts4 or Volume25 of the aircraft flight manual (AFM). Generally, those who flew with him reported that he was competent flying the aircraft. He was respected and exercised adequate command authority in the aircraft, although he preferred to work in a casual manner. 1.5.3 Operating First Officer The first officer held a Ghanaian ATPL with a valid instrument rating. He was qualified and certified in accordance with the GCARs. His last medical was conducted on 17August2004 with no annotations on the licence, although the medical records indicated that spectacles were worn for the eye test. The previous medical assessments were annotated with the remark holder to wear spectacles which correct for distant vision and shall have available a second pair whilst exercising the privileges of the license. Based on a review of the first officer's medical records, there was no indication of any pre-existing medical condition or physiological factors that would have adversely affected his performance during the flight. The first officer was reported to be a competent pilot and comfortable using personal computers. As the only first officer for the series of flights, he would have had to be an active crew member on duty on the flight deck for all take-offs, departures, arrivals, and landings for the series of flights. 1.5.4 Operating Flight Engineer The flight engineer's licence was valid until 12August2005 and was endorsed for B747 aircraft. He was qualified and certified in accordance with the GCARs. His last medical was completed on 13August2004 and, based on a review of his medical records, there was no indication of any pre-existing medical condition or physiological factors that would have adversely affected his performance during the flight. 1.5.5 Loadmaster The loadmaster was trained and qualified in accordance with company standards. Although a flight medical was not required in a licensing capacity, the loadmaster completed a company medical on 16September2000. He was found fit for employment and, based on a review of his medical records, there was no indication of any pre-existing medical condition or physiological factors that would have adversely affected his performance. Records indicate that the loadmaster had flown 421hours on MKAirlines Limited aircraft during the previous 90days. 1.5.6 Non-Operating Captain The non-operating captain held a Ghanaian ATPL with a valid instrument rating. He was qualified and certified in accordance with the GCARs. His licence was annotated with a requirement for corrective lenses. His last medical was conducted on 15July2004 and he was found fit for duty. Based on a review of his medical records, there was no indication of any pre existing medical condition or physiological factors that would have adversely affected his performance. The non-operating captain was the pilot-in-command during the flight from Luxembourg-Findel Airport to Bradley International Airport. 1.5.7 Non-Operating Flight Engineer The non-operating flight engineer's licence was valid until 26January2005 and was endorsed for B747aircraft. He was qualified and certified in accordance with the GCARs. His last medical was completed on 27January2004 and, based on a review of his medical records, there was no indication of any pre-existing medical condition or physiological factors that would have adversely affected his performance. 1.5.8 Ground Engineer The ground engineer held a Ghanaian maintenance licence endorsed for B747aircraft. The ground engineer was not subject to a medical for licensing purposes. During his last company medical, he was found fit and, based on a review of his medical records, there was no indication of any pre-existing medical condition or physiological factors that would have adversely affected his performance. 1.6 Aircraft Information 1.6.1 General On 08 October 2004, the number2 and number3 engines were replaced. The throttles for the number2 and number3 engines were significantly staggered from the number1 and number4 engines at reduced thrust power settings. This defect was written in the aircraft's logbook. 1.6.2 Aircraft Weight and Balance 1.6.2.1 Aircraft Empty Weight The most recent calculations for the occurrence aircraft's weight and centre of gravity were conducted after a C-check in Jakarta, Indonesia, on 18September2004. A review of the 9G-MKJ Aircraft Weight and C.G. Determination document produced by Garuda Maintenance Facilities (GMF) AeroAsia, of the Garuda Indonesia Group, indicated an aircraft basic empty weight of 157977.5kg and an empty centre of gravity of 32.50percent mean aerodynamic chord(MAC). A review of a duplicate copy of the BLT software for the occurrence aircraft, weight and balance summary page, indicated that the operating empty weight7 was 157977kg; this was actually the basic empty weight of the aircraft. The BLT also indicated that the empty centre of gravity arm was 32.3percent MAC; this varied slightly from the 9G-MKJ Aircraft Weight and C.G. Determination document produced by GMF AeroAsia, which indicated 32.50percentMAC. The occurrence aircraft carried a spares kit (also known as a fly-away kit) on board at the time of the accident flight. The kit contained spare aircraft parts and tools; MKAirlines Limited estimated the weight of the kit to be 800kg. The aircraft also carried approximately 50kg of catering for the crews. MKAirlines Limited used standard weights for the weight of the flight crew in the cockpit, totalling 270kg. None of these three weights, which totalled 1120kg, had been included in the operating empty weight in the BLT, or the mass and balance sheet that was used to calculate the aircraft weight for take-off. 1.6.2.2 Bradley International Airport Weight and Balance The occurrence aircraft had a number of cargo floor power drive units (PDUs) removed from the aircraft and blanked off because they were unserviceable. As part of the cargo load, a large roll of steel was placed on a 20-foot-long pallet for a total weight of 13206kg. When the steel was being loaded onto the aircraft, it could only be moved by the cargo loading system as far as the functioning PDUs would permit. Normally, pallets can be manhandled into position if the PDUs are unserviceable, but, because of the weight of this pallet, it could only be loaded into positions LR and MR (seeFigure1). The weight limits for positions LR and MR are 4264kg respectively, for a total weight limit of 8528kg. The weight of the steel and the pallet exceeded the limits by 4678kg. The MKAirlines Limited operations manual (OM), PartA, Chapter8, stated in part that the loadmaster/captain must comply with additional structural limits as specified in the loading manual with regard to the maximum mass per cargo compartment. If all the PDUs had been serviceable, the steel load could have been properly placed in positions HRand JR, where the limit was 13608kg. In addition to the cargo loaded at Bradley International Airport, the aircraft was loaded with 5921US gallons of JetA fuel. The take-off mass for Bradley was 239783kg, with an MAC of 25percent and a stabilizer trim setting of 4.0units. The lateral imbalance was 18248kg, which was within allowable limits. The aircraft was within the centre of gravity limits of 13to 35percent MAC for that weight. 1.6.2.3 Halifax International Airport Weight and Balance The cargo uploaded in Halifax was comprised of 18cargo pallets. On 13October2004, a local freight forwarder delivered these pallets to the MKAirlines Limited cargo handling agent at Halifax International Airport. Each pallet contained hundreds of individual STYROFOAMTM packages of fresh seafood, supported on wooden skids and secured by a cargo net. The cargo handling agency created a cargo manifest spreadsheet for the flight by taking the gross weight of each pallet, which had been supplied on the cargo manifests by the local freight forwarder. The agency then added 130kg tare weight for the weight of the pallet and netting, for the total gross weight per pallet. There were 86wooden skids supporting the fresh seafood on the cargo pallets. The weight of the wooden skids was not accounted for in the cargo pallet gross weight provided by the local freight forwarder, nor in the cargo manifest spreadsheet. Generally, wooden skids weigh between 20and 25kg; therefore, approximately 1900to 2000kg of extra weight was not accounted for in the cargo manifest. The local freight forwarder did not weigh the built-up pallets nor did the ground handling agent at Halifax International Airport have the facilities to weigh built-up cargo pallets that were provided by others. In addition to the cargo loaded at Halifax, the aircraft was loaded with 88637litres of JetA-1 fuel. The mass and balance sheet left behind at Halifax by the crew of MKA1602 indicated a total ramp fuel of 90000kg, a take-off mass of 350698kg with an MAC of 23percent, and a stabilizer trim setting of 5.8units. The lateral imbalance was 88kg. The aircraft was within the centre of gravity limits for that weight. The company pre-planned flight documentation indicated a minimum of 86690kg of fuel and a planned cargo load of 109920kg for a planned take-off mass of 353310kg. When the weight of the wooden skids (2000kg) and the combined weight of the fly-away kit, catering, and the flight crew (1120kg) were added to the 350698kg weight calculated by the crew, the actual aircraft weight would have been approximately 353800kg. 1.6.3 Take-off Thrust The B747-200 was originally certified in 1971 with JT9D-7 engines, which had a maximum thrust of 46300pounds (dry) and 47900pounds when using water injection (wet)8 on take-off. In1979, the JT9D-7Q engine was certified for use on the B747-200. It had a maximum thrust of 53000pounds; the occurrence aircraft was equipped with JT9D-7Q engines. The maximum thrust available to an engine is dependent on the air density (pressure altitude and temperature of the air) in which the engine is operating. The maximum thrust that can be used for take-off is provided in the approved AFM, and before every take-off, the flight crew must calculate the power setting of the engine to achieve the maximum thrust. To extend engine life, it is common practice to use de-rated or reduced thrust, or a combination of both, for take offs when maximum thrust is not required, such as when taking off from long runways or with light loads. De-rated thrust is a take-off thrust level less than the maximum take-off thrust for which a separate set of limitations and performance data exists in the AFM. The occurrence aircraft had a de-rated thrust of 46300pounds (JT9D-7dry) and was referred to as RatingII (RTGII) in MKAirlines Limited documentation. Reduced take-off thrust is a thrust setting up to 25percent less than the maximum or de-rated take-off thrust. A reduced thrust setting is not restrictive in that it allows the flight crew to use maximum thrust at any time during the take off, if desired. The MK Airlines Limited OM stated that, when setting take-off thrust, the operating crew must advance thrust levers to 1.10engine pressure ratio (EPR),9 check that engine indications are stable and symmetrical, then advance thrust levers to approximately 1.20EPR and call for max thrust10 to be set by the flight engineer. 1.6.4 Aircraft Performance Data According to the B747 AFM, Section4, Performance, the stall speed for flap20, at idle power and 353800kg, is 133knots calibrated airspeed (KCAS). The stall speed is based on the aircraft in-flight and out-of-ground effect. The expected minimum unstick speed (Vmu)11 for the Halifax International Airport configuration was determined to be approximately 1502KCAS. The B747has an over-rotation stall warning system that activates a control column shaker during take-off when the rate or angle of rotation is excessive. The warning is deactivated when a body landing gear leaves the runway. Two stall warning systems are activated when the nose gear leaves the runway. Control column shaker was not a recorded value on the flight data recorder(FDR). The B747 AFM indicated that, for the pressure altitude and airport temperature at the Halifax International Airport at the time of the occurrence, an EPR setting of 1.60was required for maximum thrust, with a maximum reduction of 0.21EPR for reduced thrust. The de-rated maximum thrust EPR setting was 1.43, with a maximum reduction of 0.14EPR for reduced thrust. Climb power for the occurrence flight, derived from the MKAirlines Limited quick reference handbook (QRH), was 1.33EPR. During a reduced thrust take-off, some pilots at MKAirlines Limited would set climb EPR rather than take-off EPR if the climb EPR was the higher value. Go-around power from the QRH was1.52EPR. 1.6.5 Tail Strike Information According to the aircraft manufacturer, the B747-200 lower aft fuselage will contact the ground at a pitch attitude of 11.1 with static body gear oleo compression, and 13.1 with the body gear fully tilted and the oleos fully extended. The MKAirlines Limited OM indicated that the normal target pitch attitude for rotation is 12 with a rotation rate of 2 to 3 per second; lift-off should occur at approximately 10 pitch attitude. The manufacturer has determined that, for every five knots of airspeed below rotation speed (Vr),12 the angle of attack must be increased by 1 to gain the equivalent amount of lift during the rotation. 1.7 Meteorological Information The 0600 Halifax International Airport weather was as follows: wind 250true(T) at five knots, visibility 15statute miles (sm), overcast clouds at 1700feet above ground level (agl), temperature 10C, dew point 9C, and altimeter setting 29.67inches of mercury (inHg). The weather issued at 0700 was as follows: wind 260T at six knots, visibility 15sm, overcast clouds at 1800feetagl, temperature 10C, dew point 9C, and altimeter setting 29.67inHg. The airport's terminal area forecast corresponded to the actual weather. 1.8 Aids to Navigation At the time of the accident, the crew was using visual references for the take-off and was not relying on ground-based navigation aids. No discrepancies were discovered with the aids to navigation. 1.9 Communications All communications between the Halifax International Airport air traffic controllers and MKA1602 were normal, and there were no deviations from published procedures. There were, however, some problems with the Aircraft Rescue and Fire Fighting (ARFF) communications (See Section1.14.3 of this report). 1.10 Aerodrome Information 1.10.1 Introduction The Halifax International Airport is located at latitude 4452.85'N and longitude 06330.52'W, at an elevation of 477feet. It is a certified aerodrome operated by the Halifax International Airport Authority (HIAA) on land leased from Transport Canada (TC). Runway24 was in use at the time of the accident. It is oriented 234 magnetic(M), constructed of asphalt and concrete, and is 8800 feet long by 200feet wide. Runway24 has a published take-off run available of 8800feet and a clearway of 1000feet, providing a take-off distance available of 9800feet. 1.10.2 Airport Electrical Power Supply Just before impact, the aircraft severed a power cable and several telephone cables supplying the airport. Four diesel generators with auto-start capability, available to provide backup power to the airport power grid, started when the power cable was cut. Three of the generators supplied power to the airport grid; however, a circuit breaker tripped due to a power surge when the aircraft cut through power lines adjacent to the main crash site, preventing the fourth generator from supplying power. Approximately one hour after the accident, power from the fourth generator was restored when technical personnel manually reset the main circuit breaker. The control tower at Halifax International Airport was equipped with a separate stationary uninterruptible power unit and an independent backup power generator; consequently, there was no loss of electrical power to the tower. The Halifax International Airport fire hall normally would receive backup power from two of the four generators mentioned above. The generator with the tripped circuit breaker should have powered a relay to permit operation of the following fire hall systems: bunkroom lights, vehicle bay lights, and the automatic opening of the vehicle bay doors. Because these systems were not powered, the firefighters had to respond in a darkened environment, and the vehicle bay doors had to be opened by pushing the manual door-open button at each bay. Because the door motors were powered by an operating generator, the doors then opened. The vehicle bay lights in the fire hall were high-pressure sodium bulbs, which take approximately 10 minutes to reach full brightness; therefore, they would have been ineffective in a quick response scenario. Had the fourth generator operated as expected, it would have taken 25to 30seconds for the bunkroom lights to come on, because of the time it would have taken for the fourth generator to reach full capacity. The fire hall had been equipped with self-contained battery-operated lights; however, when the emergency power generators were installed, these lights were removed. 1.10.3 Runway 24 Slope In 2002, TC requested that NAV CANADA13 publish a slope of 0.17percent down for Runway24 at Halifax International Airport in the Canada Flight Supplement and the Canada Air Pilot. TC's TP312, Aerodrome Standards and Recommended Practices, Section3.1.2.1, described how to calculate runway slope. Using TP312, investigators from the Transportation Safety Board of Canada (TSB) calculated the slope for Runway24 to be 0.19percent up. This error in direction and magnitude was not detected by NAV CANADA personnel before this information was published, nor was the error detected during subsequent reviews of these publications by the airport operator. There are no standards for publishing slope values or slope changes for runways at Canadian airports, except that NAV CANADA documentation indicates that a slope of less than 0.3percent is not to be published. Runway24 has several slope changes. The two most significant are from the threshold of Runway24 to the highpoint of the runway, which is 6975feet from the threshold. The slope for this section is 0.24percent up. The slope for the remaining 1825feet is 0.55percent down. The total absolute change in slope is 0.079percentup. A review of non-Canadian aeronautical publications available to flight crews revealed conflicting information. One of these publications did not indicate any slope information for Runway24. Another publication had the correct value and direction. A third described the slope for Runway24 in two segments. The BLT runway information for Runway24 was imported from a SITA14 data file on 19September2003 at 0952. It stated that Runway24 had a slope of 0.08percent up and a field length of 8800feet, plus 150feet of paved overrun. International Civil Aviation Organization (ICAO) Annex15, Aeronautical Information Services, Part3, specifies that the detailed description of runway physical characteristics for each runway is to include information on the slope of each runway and its associated stopways. Chapter2 of ICAO Annex4, Aeronautical Charts, Paragraph2.17.1, states in part, States shall insure that established procedures exist in order that aeronautical data at any moment is traceable to its origin so to allow any data anomalies or errors, detected during the production/maintenance phases or in the operational use, to be corrected. The Canadian Aviation Regulations specify that the operator of an airport shall review each issue of each aeronautical information publication on receipt thereof and, immediately after such review, notify the Minister of Transport of any inaccurate information contained therein that pertains to the airport. 1.10.4 Earthen Berm An earthen berm, with a concrete slab on top to anchor the localizer antenna, was located 1150feet from the end of Runway24 on the extended centreline (see photos 2, 3 and 4). This berm was constructed in the fall of2003 to support a new localizer antenna at a height necessary to meet ICAO localizer signal coverage requirements. The berm was 11.6feet high, but since the terrain sloped downwards from the end of the runway, the concrete pad on top of the berm was in fact the same elevation as the end of the runway. The localizer antenna projected another 10feet from the top of the berm. At the same time, a similar berm was constructed off the end of Runway06 at a distance of 650feet from the end of the runway. There are similar earthen berms in use at other airports in Canada, including one at Fredericton, New Brunswick, and several at Toronto/LesterB. Pearson International Airport, Ontario. NAV CANADA submitted an Aeronautical Obstruction Clearance Form to TC on 27August2003 for the construction of both berms to support new localizer antennae. Approval was received on 08September2003. However, airport personnel raised a number of concerns when the berm on the approach to Runway24 was first being constructed, primarily because it was thought to be a potential hazard. The HIAA corresponded with TC and requested clarification on whether the berm would affect the airport's certification. Based on an inspection of the berm by TC personnel, TC advised the HIAA in a letter dated 08October2003 that the berms for the new localizers on both Runway06 and Runway24 were not in conflict with airport certification standards. In a follow-up letter from TC to the HIAA on 22October2003, TCstated, Based on information supplied by NAV CANADA, we have determined that the subject localizers are in compliance with airport certification standards. Additionally, clearways are not affected and the existing TODAs [take-off distances available] will remain unchanged. The letter concludes, Thus, from an airport certification perspective, we have no concerns about the installation of the new localizers on Runway06 or Runway24. Airport certification standards are contained in TP312. Each end of runways06 and 24had a clearway to ensure that there was an obstacle-free zone for departing aircraft. An obstacle-free zone comprises the airspace above the approach surface, inner transitional surfaces, and that portion of the strip bounded by these surfaces that is not penetrated by any fixed obstacle other than one that is required for air navigation purposes, is low mass and frangibly mounted. The HIAA did not list any obstacles, as defined in TP312, for the departure paths for runways06 and24. The earthen berm was not considered an obstacle because it did not penetrate into the obstacle-free zone. TP 312 uses the ICAO phraseology of standard or recommended practice to identify specifications considered to have a direct impact on the safety of flight from those that affect only operational efficiency. Only the standards contained in TP312 are mandatory for the certification of Canadian airports; recommended practices are optional and might or might not be implemented. One of the recommended practices in TP312 is to establish a runway end safety area (RESA). A RESA is defined as an area symmetrical about the extended runway centreline and adjacent to the end of the strip, primarily intended to reduce the risk of damage to an aeroplane undershooting or overrunning the runway. According to TP312 recommended practices, a RESA should extend from the end of a runway strip for as great a distance as practicable, but at least 90m (295feet). The runway strips for runways 06 and 24 at Halifax extend for 60m (197feet) beyond the threshold of each runway. The minimum distance specified for a RESA in the recommendations therefore would be at least 150m (492feet) at Halifax International Airport. The berms for the localizers for runways06 and 24are both located beyond these minimum recommended distances. There is no RESA published for the Halifax International Airport. ICAO considers a RESA to be a standard (ICAO Annex14, Section3.5.1) rather than a recommended practice. 1.10.5 Halifax Automatic Terminal Information Service The following automatic terminal information service (ATIS) broadcasts were issued during the time MKA1602 arrived and departed Halifax International Airport: Halifax International Airport information Victor, weather at 0400 Zulu15 - wind 260[degrees] at 7[knots], visibility 15[sm], ceiling 2200[feet asl] overcast, temperature 10[C], dew point 9[C], altimeter 2966inHg, approach ILS Runway24, landing and departing Runway24, inform ATC that you have information Victor. Halifax International Airport information Whiskey, weather at 0500 Zulu - wind 260at5, visibility15, ceiling 1800overcast, temperature10, dew point9, altimeter 2967inHg, approach ILS Runway24, landing and departing Runway24, inform ATC that you have information Whiskey. Halifax International Airport information X-Ray, weather at 0600 Zulu - wind 270at5, visibility15, ceiling 1700overcast, temperature10, dew point9, altimeter2967, approach ILS Runway24, landing and departing Runway24, inform ATC that you have information X-Ray. 1.11 Flight Recorders 1.11.1 Cockpit Voice Recorder The cockpit voice recorder (CVR) was a Collins model642C-1, part number 522-4057-010, serial number1660, that was fitted in March2004. The CVR was found under debris in its mounting bracket near its installed location (seePhoto5), and it had been exposed to fire and extreme heat for an extended period. The recording tape had melted; consequently, no CVR information was available to investigators. Although this model of recorder was not required to meet the more stringent fire test requirements that exist today, the conditions of extreme heat were such that the likelihood of any tape-based recorder surviving in those conditions is considered very low. 1.11.2 Flight Data Recorder The flight data recorder (FDR) was a Sundstrand, part number 981-6009-011, serial number2756, that was fitted in April 2004. It had a 25-hour recording capability and recorded a total of 107 parameters. The recording medium was Vicalloy tape. The FDR was found in the main cabin area forward of the wing root (seePhoto5). The FDR suffered impact and heat damage in the crash and the tape broke in two places. The FDR contained information from the previous six flights and good data for the accident flight. A small portion of data for the accident flight was not available because of the necessity to splice the tape where it had broken during the impact sequence. 1.11.3 Flight Data Recorder Data Losses The FDR data had several areas where data were lost due to signal distortion and dropouts. In some areas, the distortion was such that no recovery could be made. Data cycling causing dropouts was observed during the taxi segment, the initial portion of the take-off and the final 12seconds of the recording. The data cycling was left as valid data to show this characteristic on the data plots (before and at the start of the take-off roll), even though the recorded data for the affected parameters were not valid. This cycling was tagged as invalid in the last 12-second segment of the flight to remove the dropouts from the data plots. 1.11.4 Halifax Take-off - Flight Data Recorder Recorded Events Transportation Safety Board of Canada - AVIATION REPORTS - 2004 - A04H0004 Transportation Safety Board of Canada Common menu bar links Fran�ais Home Contact Us Help Search canada.gc.ca REPORTS AVIATION 2004 A04H0004 Institutional links Main Links TSB Home Proactive Disclosure Marine Pipeline Rail Air Air Investigation Reports Recommendations and Assessments of Responses Board Concerns Air Statistics Reporting an Air Occurrence Air Investigation Reports Recommendations and Assessments of Responses Board Concerns Air Statistics Reporting an Air Occurrence AVIATION REPORTS - 2004 - A04H0004 Factual Information (Cont'd) 1.13 Medical Information All the occupants were identified by DNA testing, and where dental records were available, they were used to verify the identity of the crew members. Forensic examination and toxicology tests did not indicate any physiological conditions or the presence of foreign substances that might have impaired the performance of any flight crew member. 1.14 Fire 1.14.1 General The Halifax International Airport ARFF met the service standards specified in the Canadian Aviation Regulations, PartIII, Section323, Aerodrome and Airport Standards, which refer to aircraft fire fighting at airports and aerodromes. The ARFF at Halifax International Airport was last inspected by TC on 27November2003 and no deficiencies were found. On 29July1997, a Mutual Aid Fire Fighting Agreement was signed between Halifax International Airport ARFF and the Halifax Regional Fire and Emergency Service. This type of agreement is often used by airports and municipal fire departments to outline the responsibilities of the parties involved where one agency requires the other's assistance. Although the agencies had the mutual aid agreement, there had only been limited opportunities for mutual inter-agency training. On seeing the fireball of the aircraft, the Halifax International Airport tower controller activated the crash alarm. The airport ARFF units responded and arrived at the accident site approximately five minutes after the crash alarm sounded; the site was on airport property, but outside the airport perimeter security fence. The Halifax Regional Municipality (HRM) Fire Department, the Enfield Fire Department, Emergency Health Services and the Royal Canadian Mounted Police (RCMP) all responded within minutes of the accident. The RCMP established a security perimeter and controlled access to the site. 1.14.2 Grid Map The HIAA Emergency Plan Manual contained a grid map of the Halifax International Airport that depicted the airport runways, taxiways, structures, roads, security fence, and the airport property boundaries. The map was divided into a numbered and lettered grid to permit rapid and clear identification of any response area. Copies of the grid map were posted in the airport fire hall, the ATC tower cab, the security operations centre and the emergency operations centre, and were carried in all airport emergency vehicles. On hearing the crash alarm, the fire brigade captain in the airport fire hall contacted the air traffic controller over the crash phone to get confirmation that an emergency situation was in progress. The location of the accident site was described to him in general terms of the area and direction, which was normal controller practice; grid map coordinates were not used. When the airport firefighters departed the fire hall, they saw the fire and proceeded to the accident site. The NAV CANADA air traffic controllers were provided training on how an aerodrome grid map is used to identify areas of an airport. In support of ARFF training at the Halifax International Airport, the air traffic controllers had used the grid map in the past to direct the response of the firefighters to different locations in the airport. The 911 operator directed the other responding agencies to the accident site by relaying the general location description that was available. This resulted in some confusion as to the exact location of the accident site. There are no regulations, standards or local procedures that require the use of aerodrome grid maps for emergency response and none of the other responding agencies had copies of the Halifax International Airport aerodrome grid map available in their vehicles. A TSB Safety Advisory was sent to TC following a 1998accident (TSB reportA98Q0192), on the subject of using grid maps for reliable and efficient direction during emergency responses to aircraft accidents. TC replied on 14August2000 to advise the TSB that the subject was to be addressed in a Notice of Proposed Amendment to the aerodrome safety regulations and standards. This change has not occurred to date. 1.14.3 Radio Communications Each ARFF vehicle was equipped with very high frequency, two-way radios, which were used to communicate with the air traffic controller on ground control frequency. The firefighters also had portable ultra high frequency radios that, because of a blind spot at the site, could not be used to communicate with the HIAA Emergency Operations Centre. These radios could have been used at the site for ARFF communication had they used the simplex mode, which allows direct communications at short distances. The ARFF firefighters eventually had to communicate using hand signals until they were supplied with a portable trunk mobile radio from another response agency. The Halifax International Airport ARFF had a portable trunk mobile radio unit that could have been used to communicate with outside agencies such as the Halifax Regional Fire and Emergency Service dispatch facility and the RCMP. However, it had been left at the fire hall. The firefighters also attempted to use their individual cell phones to communicate with the Emergency Operations Centre, but the signal was unreliable. 1.14.4 Site Command The Halifax International Airport ARFF firefighters were the first on the scene and took command of the situation. Although they were responding outside the airport perimeter security fence, they suspected that the aircraft was still on airport property. The HIAA Emergency Plan Manual stated that the airport's ARFF was to be the lead agency in the event of an aircraft crash on airport, and the municipal fire department was to be the lead agency in the event of an aircraft crash off airport. Although the responsibilities for on or off airport crashes were described in the different documents, the actual boundary separating the two areas was not clearly defined. In several locations, the airport property limits extended outside the airport perimeter security fence. When HRM Fire Department firefighters arrived at the accident site, they observed the aircraft to be outside the airport perimeter security fence; consequently, they assumed that they were the lead agency. A unified command post was established that included the HRM Fire Department, Emergency Health Services, the RCMP and, eventually, Halifax International Airport ARFF. This temporary confusion as to who was in command of the site did not cause significant problems. Some responders noted that there was a need for more inter-agency training. 1.14.5 Persons on Board and Dangerous Goods Information on the number of persons and dangerous goods carried on board the aircraft was not readily available to air traffic controllers in the Halifax International Airport tower. Shortly after the accident, the air traffic controllers unsuccessfully attempted to contact the ground handling agency at the airport to learn the number of persons and dangerous goods on boardMKA1602. In accordance with ICAO's Technical Instructions for the Safe Transport of Dangerous Goods by Air, shipping documentation must accompany dangerous goods on board an aircraft. The MKA1602 flight crew had copies of the shipping documentation and copies were also available at Bradley International Airport, where the dangerous goods were loaded on the aircraft. Regulations only require that copies of shipping documentation be left at an airport where the dangerous goods have been loaded; therefore, authorities at intermediate airports are not aware of all the dangerous goods that might be on board an aircraft. Approximately one hour after the accident, MKAirlines Limited operations staff contacted the Halifax International Airport control tower and informed the controller that there were seven crew members on board MKA1602. This information was immediately relayed to ARFF and to the HIAA Emergency Operations Centre. At 0840, MK Airlines Limited informed the ARFF that no dangerous goods had been loaded on MKA1602 at the Halifax International Airport. At 1700, about 10hours after the accident, MK Airlines Limited sent a 30-page fax listing the dangerous goods that had been loaded on board the aircraft at Bradley International Airport. The goods included medical supplies, adhesives, paint, food flavouring, and motor vehicles. When an aircraft in flight declares an emergency, controllers get the information regarding the number of persons and dangerous goods on board directly from the flight crew. In the event that it is not possible to communicate with the flight crew, the affected company should be able to provide this information, though it might take some time. However, rarely do controllers have the required contact information for the many airline companies. 1.15 Survival Aspects The occupants were all located in the cockpit and upper deck rest area behind the cockpit. These areas were severely compromised during the impact and break-up of the aircraft. There was also an intense post-crash fire. The accident was not survivable. 1.16 Tests and Research The aircraft manufacturer was requested to provide analysis on the aircraft performance characteristics of MKA1602 during the take-off at Halifax International Airport. The manufacturer used two independent software tools to assess the take-off of MKA1602, using the FDR data from the accident and previous flights. The TSB and the United States National Transportation Safety Board (NTSB) reviewed the manufacturer's analysis. It was found that the performance characteristics of MKA1602 were consistent with that expected for normal operation. The simulation EPRs and recorded FDR EPRs were similar, further validating the simulation models for the take-off roll condition. Both software tools provided a consistent result that showed the actual weight of the aircraft to be reasonably near to that calculated by the TSB for the attempted take-off at Halifax International Airport. The manufacturer's engineering analysis also provided a hypothetical flight path the aircraft would have taken if the berm had not been present. Limitations of the software and the many assumptions required to model such a take-off (where the aircraft lower aft fuselage is dragging) made it difficult to determine a clear result. However, assuming that the performance of the aircraft remained as it was before impact with the berm, it is considered likely that the aircraft would have stayed airborne, possibly contacting tree tops located 2000feet beyond the end of the runway. The elevation of the top of the berm was the same as the end of the runway, and the tree tops were estimated to be at about the same elevation as the berm or slightly higher (seePhoto3). 1.17 Organizational Information 1.17.1 MK Airlines Limited 1.17.1.1 General The company began operations with a single DC-8 aircraft in 1990as Cargo d'Or, using a Ghanaian air operating certificate (AOC). During this same period, the airline established an office in the United Kingdom near Gatwick Airport to facilitate general sales for the company. In1993, the company invested in another airline in Ghana called Venus Air, and transferred the Cargo d'Or aircraft to the Venus AirAOC. Concurrently with the transfer, the name of the airline was changed to MKAirlines Limited. In November1993, the commercial offices in Gatwick were moved to the present location at Landhurst, East Sussex. The enhanced communication and infrastructure potential at the new location facilitated improved in-house management functions, flight training, maintenance, crew scheduling, and operational control. As the company expanded, more DC-8 aircraft were added to the fleet and more employees joined the company. Most of the new flight crew members were from southern Africa, and many had a military background and/or a previous connection with the managing director or other employees of MKAirlines Limited. The company philosophy was to provide people from that geographic area with employment opportunities that would not otherwise exist. The first B747 aircraft was added to the company's fleet in1999. At the time of the accident, the company was operating six DC-8 and six B747aircraft. Over the last several years, the company had increased its fleet by approximately one aircraft each year to accommodate the growing demand for cargo capacity, which was increasing by approximately 30percent each year. At the time of the accident, the company employed about 450people. However, it was reported by several flight crew members that there were crew shortages, especially on the B747. These shortages were due to company expansion, training demands, and crew retention issues (see Section1.17.1.5 of this report). At the time of the accident, MK Airlines Limited held a Ghana Civil Aviation Authority (GCAA) AOC (No.16/18/2003), issued 22December2003 and valid until 31December2004. The AOC was granted for the purpose of public transport, passengers, mail, cargo, and aerial work with B747 and DC-8 aircraft. The company had an extensive intercontinental route structure with many of the routes being long, triangular patterns to best serve the market demands. 1.17.1.2 Flight Operations Supervision and Oversight The MK Airlines Limited OM described how the company would manage its flight operations. In anticipation of Ghanaian parliamentary passage of the 2002GCARs (see Section1.17.2.2 of this report), the OM also described some programs that were not fully developed or implemented, such as the flight operations quality assurance and flight safety program. In accordance with the MK Airlines Limited OM, the Operations Manager was responsible for ensuring that an adequate level of flight operations supervision was maintained. For up to two years before the accident, the Operations Manager position was filled by the B747 fleet captain in an acting capacity. In addition to his duties as the acting Operations Manager, his responsibilities as the B747fleet captain required him to do a considerable amount of line flying. His line flying enabled him to exercise adequate supervision of operations and allowed crews to express their concerns and raise issues directly to him. However, some of the operations management responsibilities were not being fully carried out. For example, the OM was not being kept up to date, the supervision of flight and duty limitations was lacking in some areas, and consistent adherence to SOPs was not being assured. Many of the MK Airlines Limited flight crew had similar backgrounds. Employees of the company had a familial approach to business, which permeated all levels, including the line crews and supervisory/management personnel. This familial environment resulted in both positive and negative consequences for the company. For example, on the positive side, it provided a strong sense of loyalty and commitment to the success of the company. On the negative side, it created an environment where managers and supervisors could have had difficulty ensuring that their friends adhered to company procedures and policies. For example, some supervisory pilots had noted occurrences of non-adherence to SOPs when they were non-operating crew members. These were not brought to the attention of the crew, nor were they reported to the company because of this familial relationship and their status on the flight. It was noted that several supervisory pilots had flown the MKA1601/MKA1602 flights, where the maximum allowable duty hours were exceeded with no action being taken. Due to the nature of the non-scheduled air cargo operations and the routes that were being flown, there were ongoing, significant challenges faced by management and crews. These included departure delays, schedule changes, aircraft unserviceabilities, inhospitable destinations, and crew flight-time limitations. In this context, both management and crews occasionally felt it was appropriate to deviate from company policy and procedures to accomplish the mission. This was done believing that the risk in doing so was manageable. 1.17.1.3 Flight Operations Quality and Flight Safety Program The flight operations quality and flight safety program described in the OM was relatively new and had been somewhat slow in developing. The company wanted a program developed in house and one that reflected the company culture, rather than one that was off the shelf. Company management reported that they had an open approach to flight safety and regarded it as being very important. Safety information was distributed quickly to crews through their computer-generated flight briefs. At the time of the accident, some components of the flight operations quality and flight safety program described in the MK Airlines Limited OM were not actually being carried out, or were only being partially carried out. Although there was an occurrence investigation system and occurrence tracking software had been acquired, the database was still being developed. There was no confidential reporting system. There was no flight operations quality assurance audit program in place for flight operations. However, the company had been assessing a number of different systems for the retrieval and analysis of FDR information. 1.17.1.4 Company Aircraft Training and Testing MK Airlines Limited had been undergoing rapid expansion, especially in the B747 operation. The company had evolved from outsourcing almost all of its training to having a complete in house capability. At the time of the accident, the company was conducting approximately sixB747 conversion courses each year. The company operated its own flight simulators, oneB747 and oneDC-8. The company also had a comprehensive 40-hour flight crew indoctrination training program that was required for all newly hired flight crew. The MK Airlines Limited OM, PartD - Training, AppendixA, contained a ground and simulator training course syllabus for the DC-8. There was no equivalent B747 ground and simulator course syllabus in the OM, PartD; however, there was a separate manual describing a ground training syllabus and a simulator training program. The B747 classroom instruction was supplemented by practical application of the subject matter in the simulator. The simulator flight training syllabus was quite extensive; 14four-hour sessions were provided with a proficiency check and instrument flight test conducted after these sessions. A system of tracking the training required by different crew members and the filing of the different training records was in place; however, when TSB investigators requested training files of the occurrence crew, some documents were missing or were difficult to locate. Training on new technology equipment and software, such as the BLT, was done by self-study and hands-on experience, using training material developed from the manufacturer's software manual. The information was distributed through notices to flight crews but had not been incorporated into the OM. There was no formal documentation to record an assessment of the individual's knowledge and competency using the equipment. The company had a dedicated, experienced and knowledgeable group of supervisory pilots and flight engineers in its Training Department. One aspect stressed by the Training Department during training sessions and line checks was the strict adherence to SOPs at all times. Generally, most employees felt the training was adequate and the SOPs were appropriate for the operation. The operating philosophy among most flight crew was that SOPs were to be followed unless there were justifiable extenuating circumstances. 1.17.1.5 Crew Pressures A significant number of MK Airlines Limited employees, particularly flight crew members, lived in southern Africa. Because of the company's business locations and route structure, employees were separated from their families for weeks at a time when on duty. With the political and social unrest in some of these areas, there was the potential for harm to come to their families when the employees were away. There were several examples cited where employees' families had experienced incidents of home invasion and/or personal attack. This was identified as a source of stress within the company. In an effort to improve working conditions at MK Airlines Limited, the managing director had requested, some time before the accident, that the captain of MKA1602 submit a letter on behalf of the crews, listing some general concerns and suggestions of other flight crew. The letter was submitted shortly before the accident, and the company voluntarily supplied it to the TSB investigators. The letter indicated concern about recent increases in the number of pilots leaving the company and suggested that a new compensation package should be put in place to provide a more stable financial situation for flight crew members. The letter also indicated that there were not enough crews per aircraft. As well, it discussed the uncertainty of life for those living in southern Africa, indicating that the lengthy periods away from home increased stress and contributed to flight crew members looking at other employment options. The letter mentioned that inexperienced operational support personnel, combined with pressure from the Commercial Department, were causing crew scheduling difficulties. Other company employees reported that there was a consistent shortage of B747 flight crew and they were required to spend lengthy periods away from home. To address a crew shortage in the past, the company had hired flight crew members from Argentina on contract to supplement its DC-8 operation. 1.17.1.6 Company Maintenance Practices A review of the technical records indicated that all requirements of the approved maintenance program had been completed on the accident aircraft in accordance with the variation/tolerance approved by the GCAA. 1.17.2 Ghana Civil Aviation Authority 1.17.2.1 General Since 1991, the GCAA has invested in personnel, training and equipment to help ensure conformity with ICAO standards and recommended practices (SARPs). In1993, the GCAA requested assistance from Canada in the form of a safety review by TC. Following this review, a report was provided to the GCAA that identified areas for improvement, including a rewrite of the regulations and development of oversight guidance for inspectors. Several Canadians were contracted in 1995to assist the GCAA in this effort. A new set of regulations came into effect in1995. 1.17.2.2 Ghana Civil Aviation Regulations The regulations that were in force at the time of the accident were the 1995GCARs. In1997, ICAO identified that these regulations needed to be updated. ICAO conducted an audit of the GCAA in April2001 and noted in its report that the GCAA's corrective action to the audit findings was generally satisfactory. The audit also determined that the newly drafted GCARs (referred to as the 2002version) were in compliance with most of the SARPs, but had not yet been approved by the Ghanaian parliament. An audit follow-up was conducted in May2003 to determine the progress made on the corrective action. It was noted that some progress had been made, but the GCAA's regulatory efforts were being hampered by the ongoing delay in bringing the new regulations (2002GCARs) into force. ICAO noted at that time that Ghana had five AOCs issued and there were two approved maintenance organizations. On 11November2004, the parliament of the Republic of Ghana approved the Civil Aviation Act, 2004, which brought into law the 2002version of the regulations. 1.17.2.3Ghana Civil Aviation Authority Flight Operations Oversight The GCAA was asked to provide all records of all inspections, audits, and correspondence related to MKAirlines Limited for the two-year period before the accident at Halifax International Airport. The GCAA operations inspection file for MKAirlines Limited was reviewed to determine the actual frequency of inspections and to assess the handling of any safety deficiencies identified by the GCAA. It was concluded that the actual inspections conducted during the two years before the accident were below the minimum frequency of about 20inspections indicated in the inspector's handbook. The inspection frequency of MKAirlines Limited had been decreased due to increased vigilance and the inspection of another registered Ghanaian operator. A GCAA base inspection in September2003 identified areas in the MK Airlines Limited OM that needed revision; however, many other areas were not identified as being out of date, not being followed, or in conflict with the regulations. An example of OM conflict with regulations was the practice of one pilot leaving the cockpit for prolonged periods during a flight. Although this was identified as a deficiency during a GCAA in-flight inspection, and formally recorded, the GCAA inspector was apparently unaware that the MK Airlines Limited OM, Section8.3.10.1 (revised in2001), provided for a flight crew member leaving his assigned station for an agreed purpose and period with the permission of the captain. It must be noted that OM, Section8.3.10.1, contradicted OM, Section7.4, which prohibited the pilot from leaving his duty station for a prolonged period. Although the GCAA was asking for compliance with the 2002GCARs, the company felt that the 1995 version was still in effect, and this might have led to different interpretations. The 1995version of the GCARs stated that, if the aircraft is required to carry two pilots, the commander shall cause both the pilots to remain at the controls for only the take-off and landing. The GCAA reported that it was not aware of the rest, duty and flight time scheme in use by the company at the time of the accident, even though it had been in use and included in the company OM for two years. 1.17.2.4Ghana Civil Aviation Authority Airworthiness Oversight The 1995 GCARs indicated that periodic checks were to be carried out by the GCAA, and that these checks were to be done in conjunction with supervisory visits. These regulations did not specify the frequency or quantity of these checks or visits. The GCAA airworthiness inspectors had participated in the base inspection of MKAirlines Limited Landhurst facilities in September2003. Additionally, it was reported that the GCAA carried out on-site visits for the annual renewal of each aircraft's Certificate of Airworthiness. During these visits, the GCAA would carry out an inspection that focused on examining the aircraft and reviewing the applicable technical documents. With a fleet of 12 aircraft, the GCAA would be at MK Airlines Limited facilities at least 12times per year to carry out inspections. Although some discrepancies were noted during the airworthiness review of MKAirlines Limited, overall, it appeared that the GCAA was providing an adequate level of airworthiness oversight. In a letter from the GCAA to MKAirlines Limited after an airworthiness audit, it was noted that amendments that had been incorporated in the maintenance control manual and the minimum equipment list had not been referred to the authority for prior approval. The GCAA did not receive a corrective action plan promised by MK Airlines Limited from the base inspection in September2003. 1.17.3 Transport Canada TC's Foreign Inspection Division conducted a base inspection of MK Airlines Limited operations in the United Kingdom between 15August and 26August2002. The closing paragraph of the base inspection report stated that the company would be issued a Canadian Foreign Air Operators Certificate upon receipt of an acceptable corrective action plan that addressed the findings of the inspection. MKAirlines Limited submitted a corrective action plan in October2002. On 20 December2002, TC's Foreign Inspection Division granted MKAirlines Limited Canadian Foreign Air Operators CertificateF 10326. The Division had some concerns about issuing the certificate because of MKAirlines Limited accident history (see Section1.18.6 of this report). However, the Division was impressed by MKAirlines Limited management, the timeliness and content of the corrective action plan, and the quality of feedback from the United Kingdom Civil Aviation Authority (CAA). Contributing to the confidence of the decision was the FAA's assessment that the GCAA was a Category1 regulatory authority. 1.17.4 United States Federal Aviation Administration The FAA established the International Aviation Safety Assessments (IASA) program in August 1992 to assess the ability of foreign civil aviation authorities to ensure compliance with ICAO's SARPs. There are two IASA safety ratings with regard to the SARPs: does comply (Category1) and does not comply (Category2). Specifically, the FAA determines whether a foreign civil aviation authority has an adequate infrastructure for international aviation safety oversight as defined by ICAO standards. The basic elements that the FAA considers necessary include the following: laws enabling the appropriate government office to adopt regulations necessary to meet the minimum requirements of ICAO; current regulations that meet those requirements; procedures to carry out the regulatory requirements; air carrier certification, routine inspection, and surveillance programs; and organizational and personnel resources to implement and enforce the above. In 1996, the FAA assessed the GCAA as having a Category1 safety rating. On 02 June2003, the FAA granted MKAirlines Limited authority to operate in the United States by issuing Operations SpecificationZM0F869F. As part of the FAA's oversight, periodic ramp inspections were conducted on MKAirlines Limited aircraft. In July2004, MKAirlines Limited was placed on a special emphasis list. This list is issued semi-annually to identify foreign air carriers that are to be watched. The list also includes countries with a Category1 Civil Aviation Authority, where the FAA has concerns. In September2004, a ramp inspection of an MKAirlines Limited aircraft resulted in a decision to increase surveillance of the company's operation. A ramp inspection of an MK Airlines Limited DC-8 in the United States following the accident in Halifax identified several deficiencies, and on 29October2004, the FAA informed the company that its Operations Specification was cancelled; no specific reason was stated. In December 2004, the FAA conducted a reassessment of the GCAA and, on 30 April2005, it announced publicly that Ghana had failed to comply with ICAO standards. As a result, Ghana's safety rating was lowered to Category2. 1.17.5 United Kingdom Civil Aviation Authority Within the United Kingdom, the Department for Transport will issue a permit to a foreign-registered airline to operate into the United Kingdom if the airline has all the relevant approvals from its regulating authority. Where the Department has reason to believe that an airline or aircraft might not comply with international standards, it can arrange for that airline's aircraft to be inspected by the CAA. Where the CAA finds a matter requiring attention, it will be raised with the aircraft crew, airline, and/or foreign authority as appropriate. The Department for Transport relies on the country of registry to carry out effective and ongoing oversight of the company. The Department had issued permits to MKAirlines Limited, and the United Kingdom CAA had conducted a number of ramp inspections on MK Airlines Limited before the accident, without any significant findings. 1.18 Other Relevant Information 1.18.1 Boeing Laptop Tool 1.18.1.1 Introduction At the time of the accident, MK Airlines Limited was using the Boeing Laptop Tool (BLT) for determining performance calculations. The BLT is a Microsoft Windows-based software application used to calculate take-off performance data, landing performance data, and weight and balance information (seeFigure2). The performance data in the software are a digitized form of the approved B747AFM. Figure2.BLT take-off and landing performance page The weight and balance data were supplied by and built into the software by MKAirlines Limited, and Boeing provided training to the MKAirlines Limited software administrator. The MKAirlines Limited BLT software administrator was responsible for setting up the weight and balance page for each specific aircraft and for supplying the airport database for the BLT. Boeing did not approve or review the work that the company administrator had done to the BLT weight and balance page. The company administrator had the option to lock out the weight and balance page in the BLT to prevent crews from using it; however, MKAirlines Limited decided not to lock out the weight and balance page in order to leave the page as a cross-check against the loadmaster's manual calculations. MKAirlines Limited had also received a current Boeing Administrator's Guide, with comprehensive instructions and the latest revisions to the software. The software version in effect at the time of the accident was version 2.69r, effective 24May2004. Each B747 in MKAirlines Limited's fleet had been equipped with a laptop computer with a touch screen and printer stored in the upper deck. The BLT software installed on each laptop was aircraft-specific because of the differences in engines and weight and balance among aircraft. The weight and balance feature of the BLT software allowed a user to perform basic weight and balance functions, including the calculation of the stabilizer trim setting for take-off. This software feature was an option that MKAirlines Limited had activated. The weight and balance feature was accessed via a dedicated button on the main input dialogue screen, which would bring up a weight and balance summary page. The user could enter passenger weights, cargo zone weights, and fuel for the flight. When that information was entered, the take-off and landing weight, based on those inputs, was updated at the bottom of the summary page. Once updated, the estimated take-off weight would be passed back to the planned weight field on the main input dialogue screen and would automatically overwrite any entry in the planned weight field, without any notification to the user. 1.18.1.2MK Airlines Limited Crew Training on Boeing Laptop Tool When the MK Airlines Limited beta version19 of the BLT was ready, the Information Technology Department and the B747 Training Department began in-house testing, comparing the AFM performance section as a cross-check of the BLT using different samples of airports, altitudes, and temperatures. Differences were noted and corrected in conjunction with Boeing. The BLT was then given to the B747 Training Department instructors to begin training crews in its use. Information on the BLT was distributed to flight crews in the form of newsletters and notices to flight crews. On 09 February2004, the MKAirlines Limited B747 chief training pilot issued a Notice to Flight Crew to the B747 flight crew (including loadmasters) on the subject of the BLT. It stated the following: Please find attached the Performance section and relevant QRH pages. Please take the time to study these for when the BLT program is put onto the onboard computers. The BLT will eventually replace the Airport Analysis Charts.20 This Notice to Flight Crew had a detailed 46-page manual attached on the use of the BLT to calculate performance data, which was issued as an amendment to the company OM, PartB, for the B747-200 series, Section4, Performance. The self-study training material was to be read by the pilots, and they were encouraged to practise using the laptop on board each aircraft. If the pilots had questions or comments about the BLT, they were to be sent to the company. Line training captains conducting line checks provided some training, and some crews received BLT training during their regular recurrent aircraft training at Landhurst. Most of the MK Airlines Limited flight crew members did not receive any formal training on the BLT, and there was no method to evaluate and record if individuals had become competent using the BLT by the end of the self-study training period. Company Training Department and management personnel were aware that some pilots were not comfortable using personal computers. No additional general computer training was offered to the flight crews. However, according to the management of MK Airlines Limited, none was ever requested. The 46-page BLT manual issued 09February2004 had two references to a BLT feature regarding the planned weight dialogue box on the performance page. Whatever weight appeared in the dialogue box would be overwritten automatically with the estimated take-off weight from the weight and balance page, when the user moved from the weight and balance page to the performance page. On 29March2004, MKAirlines Limited issued a second Notice to Flight Crew for the B747fleet, informing the crews that the BLT software had been installed on all aircraft computers and was approved for calculating performance data. This two-page Notice to Flight Crew asked that the crews use the procedure as written to complete take-off data cards. The first page was an instruction to pilots, while the second page was an instruction to loadmasters. It stated in the loadmaster instructions that, when closing the weight and balance page, the take-off weight as listed in the weight and balance page will now appear in the planned take-off weight block. There was no mention of this feature in the instructions to pilots. This Notice to Flight Crew also requested that the flight crew members take time to read the BLT manual. It could not be determined if the occurrence flight crew read the BLT manual issued in February, or the simplified instructions issued in March. Reports from other MKAirlines Limited flight crews indicated that the operating captain was not comfortable using the BLT, while the first officer had been observed using it. On 12 August 2004, MK Airlines Limited issued a Notice to Flight Crew, which stated the following: Airport (runway) analysis charts will be removed from all aircraft libraries in the near future. All performance calculations are to be performed using the BLT. In the unlikely event that no BLT computers are working then please revert to Volume2 for the calculations and make sure a MAX THRUST Take Off Data Card is used. 1.18.1.3 Performance Data from the Boeing Laptop Tool When the BLT software was opened, the introduction page presented the user with the option of two engine ratings for calculating take-off performance data: maximum take-off power using JT9D-7Q engine performance, identified by the aircraft registration (9G-MKJ), or de-rated power/rating II (RTG II) using the JT9D-7 dry engine certified performance, identified by RTG II. Once the screen of the appropriate power rating is selected, the user inputs the airport and atmospheric data. The user then selects the calculate button and the BLT will indicate the maximum take-off weight for that runway and the EPR setting for maximum thrust for that power rating. The maximum thrust take-off performance data are displayed on the upper right of the screen, and the reduced thrust take-off performance data are displayed in the lower right side of the screen. The performance data on the right of the screen also include the aircraft weight on which the data were based. The user then transfers the appropriate data to a take-off data card (seeFigure3). 1.18.1.4 Maximum Allowable Take-off Weight at Halifax Based on the atmospheric conditions at Halifax International Airport at the time of the accident and for a take-off on Runway24, the BLT would have indicated that the maximum weight for a maximum thrust (JT9D-7Qengine) take-off would be 355230kg, and the maximum weight for a RTGII take-off would be 321580kg. The maximum weight for a reduced thrust take-off using the JT9D-7Q engine would be 346513kg, and the maximum weight for a reduced thrust take off using RTGII would be 315058kg. 1.18.1.5Boeing Laptop Tool Take-off Performance Data at Halifax The BLT take-off performance page would have indicated that, for a take-off weight of 350698kg (the weight taken from the mass and balance sheet left behind by the flight crew), using maximum thrust, the EPR setting would have been 1.60and the take-off speeds, respectively, would have been: V1 (take-off decision speed)=149knots, Vr (rotation speed)=161knots, and V2 (take-off safety speed)=171knots. At that weight, the BLT would not have provided reduced thrust performance data, including an EPR setting. The BLT take-off performance page would have indicated that, for a take-off weight of 353800kg (the estimated actual weight), using maximum thrust, the EPR setting was 1.60and the take-off speeds, respectively, would have been: V1=150knots, Vr=162knots, and V2=172knots. At that weight, the BLT would not have provided reduced thrust performance data, including an EPR setting. The AFM provided comparable values. If the RTGII option had been selected, any weight input into the planned weight box greater than 321580kg would have given the following warning: Planned weight exceeds max allowable take-off weight of 321580kg. An EPR setting of 1.33could have been obtained using the BLT and RTGII, reduced thrust with a minimum weight of 285000kg. At that weight, the take-off speeds, respectively, would have been: V1=137knots, Vr=145knots, and V2=151knots. 1.18.1.6Boeing Laptop Tool Take-off Performance Data at Bradley Using the atmospheric conditions at the time of take-off on Runway06 at Bradley International Airport, the BLT take-off performance page would have indicated that, for a take-off weight of 239783kg, using RTGII, reduced thrust, the EPR setting would have been 1.30and the take-off speeds, respectively, would have been: V1=128knots, Vr=128knots, and V2=137knots. 1.18.1.7Boeing Laptop Tool Take-off Performance Data at Halifax Using Bradley Weight Using the atmospheric conditions at the time of take-off on Runway24 at Halifax International Airport and a take-off weight of 239783kg, the BLT take-off performance page (seeFigure6) would have indicated the following: 1.18.1.8 Landing Performance Data at Halifax